lateral epicondylitis exercises pdf spanish
Talk to your doctor or physical therapist about which exercises will best help you meet your rehabilitation goals. SKU. There are numerous surgical approaches, including open, percutaneous, and arthroscopic techniques. ,BO:|AP%hiBhR feNH >d* Mjo If symptoms continue despite numerous treatment approaches, referral may be warranted. Diagnosis is by examination and provocative testing. 0000006614 00000 n Do 3 sets of 10. Hacer ejercicios y fisioterapia. The condition is sometimes called tennis elbow, although it often occurs with activities such as other racket sports and golf. Forearm pronation and supination: With your elbow bent 90, turn your palm upward and hold for 5 seconds. If you continue the activity that caused your condition, the pain may spread down to your wrist, even at rest. ZvZ[bX}+a ~JyvO1e1!$~x3|_r,u NM?]>haotwf23upo7;p=4F7HvhP*F Llame a su proveedor de atencin mdica de inmediato si tiene alguno de estos sntomas: Fiebre de 100.4F (38C) o superior, o segn la indicacin de su proveedor, Enrojecimiento, inflamacin o calor en el codo o el antebrazo que empeoran, Los sntomas no mejoran con el tratamiento, o empeoran, Francesca Torriani, MD 0000000016 00000 n Es la protuberancia sea que se encuentra en la parte externa del codo. an epicondylitis clasp, which can help reduce the strain on your elbow if you need to make repetitive hand and elbow movements, for example while you're working. 2000-2023 The StayWell Company, LLC. hbbd```b``.G@$3"H;``= Rp> "EH~)"yR@dFd>6-fI]@B&F' 0 u3m COVID-19 updates, including vaccine information, for our patients and visitors Learn More. These five exercises have a s. Copyright 2007 by the American Academy of Family Physicians. However, many people who suffer from tennis elbow do not play tennis. q6tO*j>w4M a\ 0000098687 00000 n Sin embargo, cada individuo puede experimentar los sntomas en forma diferente. Case series have suggested favorable outcomes with few adverse effects.31 Despite these conclusions, no RCTs have been performed.7,31. Make sure you keep your elbow at your side and bent 90 throughout this exercise. Esto ayuda a reducir el esfuerzo sobre los msculos y los tendones del antebrazo, lo que puede aliviar los sntomas. 0000203117 00000 n One case series, including 29 patients who had failed other conservative modalities, reported a 79 percent improvement in pain scores over an average of 9.5 months; some patients required multiple injections.27 However, clinical trials that include a comparison group receiving placebo injections are lacking, and until these trials are completed, autologous blood injections cannot be recommended. LE is a chronic degenerative process stemming from microtrauma (rather than an acute inflammatory process). hbbd```b``` RDjQ R~X$dT eHG Rp2fZH&O-`vzC )b"Y@O9^zFp?l2^ $_@F -%_v10T#30 0 ]N Por ejemplo, si los tendones se daaron por jugar al tenis, puede servirle de ayuda modificar su tcnica de juego o usar un equipo diferente. Usar una frula. hb```a``:( @1V,F ? ]SrHGonvHA_N;{c=Uw4Qya,t>zTrYqPf(6Yh"95g&~%Y*/9l7[2jUHe0X h :4;Pb2Lbusf "pUPU f 0000002024 00000 n Lateral epicondylitis can be treated with rest and medicines to help with the inflammation. Your forearm muscles extend your wrist and fingers. The pain is typically located just distal to the lateral epicondyle over the extensor tendon mass. 0000002669 00000 n 6~ 0 9H 0000009971 00000 n You may be able to progress onto these earlier 0000010006 00000 n Strengthening exercises Eso le ayudar a aliviar los sntomas y a evitar un mayor dao a los tendones. Exercises to treat Lateral Epicondylitis These stretches can help reduce the tightness associated with the elbow strain and pain. Patients with refractory symptoms may benefit from surgical intervention. Tennis elbow (lateral epicondylitis) and golfer's elbow (medial epicondylitis) are painful conditions caused by overuse. As the last description implies, it is a tendinopathy injury involving the extensor muscles of the forearm. The following interventions are probably helpful for lateral epicondylitis: watchful waiting, short-term topical NSAIDs, corticosteroid injection (short-term relief), exercise regimens, NSAID iontophoresis, ultrasonography. Siempre consulte a su mdico para un diagnstico. Physical therapy regimens, including strength training and stretching, are commonly used to treat lateral epicondylitis. In stock. Additional instructions: This exercise should be per-formed after completing the above staged strengthening exercises. Esta informacin no pretende sustituir la atencin mdica profesional. Repeat 8 to 12 times. 940367. 0000007632 00000 n 36 0 obj <> endobj endstream endobj 44 0 obj <> endobj 45 0 obj <>stream Slowly turn your palm downward and hold for 5 seconds. 0000001416 00000 n La epicondilitis lateral afecta los tendones que conectan los msculos del antebrazo al epicndilo lateral. Exercises often help too. For additional payment options call us at (800) 333-3032. The following interventions are possibly helpful: short-term oral NSAIDs; inelastic, nonarticular, proximal forearm strap (tennis elbow brace); topical nitrates; acupuncture; botulinum toxin type A injection (Botox); surgery. Slo su mdico puede diagnosticar y tratar un problema de salud. Surgery is rarely needed. x][u~_pwvwf0h!ERd!Y\,i|n`,S[5X/}O?_]_R?C^5u5uQe>ff"/z/Tuy1;}[f.{?e7zp* p8NgwFO^[F_do} A5e$d)>AP6r~m$vmu[y"Lnn/%i 1;;- b=\ [@}v-c( O|Dlg}w8^M'+(yrCo3MvSYCDtW{h/8C>EZ&YO`I'1hO kQ0Nk*A\)uR&. Tendons are the structures that connect the muscle to the bone and can be irritated with repetitive use. O puede aplicarlos como gel, crema o parche sobre la piel. Lo siguiente puede causar el codo de tenista: Msculos dbiles del hombro y de la mueca. For the best experience on our site, be sure to turn on Javascript in your browser. Esta informacin no pretende sustituir la atencin mdica profesional. Magnetic resonance imaging (MRI) can show your tendons and how severe the damage is. Topical NSAIDs may provide short-term pain relief.6,7 Three studies have examined the effects of diclofenac (Solaraze) and benzydamine (not available in the United States) for up to three weeks. The grip may become weak. @U( Q:^63:.3>~_^+U}9'@}z4$Uuu}jy+x'O/b"D-^Ic[xxOTLwL4)^C:IH)(. Puede ser peor al mover o usar el codo, el antebrazo o la mueca. Restart with a lighter weight or fewer repetitions. 0000003172 00000 n Lateral epicondylitis, also known as tennis elbow, is a common condition that is estimated to affect 1% to 3% of the population. This helpful brochure, now updated with a fresh new look and full-color photography, engages readers and aids comprehension of lateral epicondylitis (tennis elbow). Remember! Tennis elbow is generally caused by overuse of the extensor tendons of the forearm, particularly the extensor carpi radialis brevis. Extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy do not appear to be effective. We are vaccinating all eligible patients. El codo de tenista, como el nombre indica, a menudo es causado por la fuerza de la raqueta de tenis que golpea pelotas en la posicin de revs. Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily activities. Treatment of tennis elbow includes: activity modification, ice, medicine, stretching, braces and injections. HOk1st Hot picture Medial Epicondylitis Exercises Pdf, find more porn picture exclusive physiotherapy guide for physiotherapists exercise for medial, tratamentul epicondilitei laterale cotul tenismenului recuperare, Usar compresas fras. Place 1 lb. A tendon is a tough cord of tissue that connects muscles to bones. It is called "tennis elbow" (or what was previously referred to as lateral epicondylitis) . All rights reserved. Inicialmente, puede sentir dolor a lo largo de la parte externa del antebrazo y del codo. 619-471-9045. 3. Subscribe to receive special offers, exclusive updates, and new product announcements. endstream endobj 36 0 obj <> endobj 37 0 obj <> endobj 38 0 obj <>stream 8znYkD%RJ COm#Z&.a?l:|uZL*n)nT E %);\Oj!LQLZ%>'28nV4,E' These stretches should be held for 20-30 seconds and repeated 5-10 times, at least twice a day. La epicondilitis lateral, tambin conocida como codo de tenista, se caracteriza por dolor en la parte externa (lado lateral) del codo El dolor es causado por dao a los tendones que doblan la mueca hacia atrs alejndose del dolor. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Qty. 0000198888 00000 n $m'W'a^Q%to^gFd rk# Lateral Epicondylitis (Tennis Elbow) Rehabilitation Exercises You may do the stretching exercises right away. endstream endobj 33 0 obj <> endobj 34 0 obj <> endobj 35 0 obj <>stream Enviar bsqueda de la biblioteca de salud, Medial Epicondylitis (Golfer's and Baseball Elbow). Bend wrist up slowly (concentric), and then lower slowly (eccentric) (similar to exercise above). Todos los derechos reservados. 0000187186 00000 n Tennis elbow (lateral epicondylitis) and golfer's elbow (medial epicondylitis) are painful conditions caused by overuse. The exact pathogenesis remains largely elusive with putative tendinosis, a symptomatic degenerative process of the local tendon. The early goal of a therapeutic exercise program is to promote muscle endurance and improve resistance to repetitive stress. With tennis elbow, some patients will find that their symptoms go away spontaneously within a year. This leads to pain and tenderness around the elbow. Use of a tennis elbow brace (usually for a few weeks) can be beneficial. Muscular biomechanics. When making a backhand stroke in tennis, the tendons that roll over the end of our elbow can become damaged. Sports such as tennis are commonly associated with this, but the problem can occur with many different activities. Short-term oral NSAIDs, strap, topical nitrates, acupuncture, botulinum toxin type A injection: B. Lateral epicondylitis, or tennis elbow, is swelling or tearing of the tendons that bend your wrist backward away from your palm. Lateral epicondylitis is diagnosed by an exam of the elbow joint. Your healthcare provider can usually diagnosis your tennis elbow by a physical exam. This leads to pain and tenderness around the elbow. COVID-19 updates, including vaccine information, for our patients and visitors Learn More. 0000203553 00000 n Dado que esta afeccin a veces puede ser causa de jugar al tenis, tambin se llama codo de tenista. Following a well-structured program will help you return to daily activities, as well as sports and other recreational pastimes. Todos los derechos reservados. Share. To date, no studies have investigated this treatment method in patients with medial epicondylalgia. Puede ser por cualquier actividad que sobrecargue repetidamente los msculos extensores del antebrazo o los tendones y la mueca. Electromyography (EMG) of your elbow may show if you have any nerve problems that may be causing your pain. Eso puede producir dolor en el codo, el antebrazo y la mueca. Puede tomarlos en forma de pastillas. Repetitive wrist dorsiflexion with supination and pronation causes overuse of the extensor tendons of the forearm and subsequent microtears, collagen degeneration, and angiofibroblastic proliferation. 129 0 obj <>stream View Show abstract Masks are required inside all of our care facilities. Exercise Program for Epicondylitis STRENGTHENING EXERCISES Repetitions 10 reps, 1x day Days per week 5 to 7 8. 0000199142 00000 n & Hg\13:q[8la 5hMKj/ cbU9!Y8Q@Nh"7>Pp7'`aP72+X?X3'l'Sd9 Advice from a Certified Hand Therapist: What is Tennis Elbow? Rotator Cuff and Shoulder Conditioning Program, Therapeutic Exercise Program for Epicondylitis (Tennis Elbow / Golfers Elbow). Objective this study was done to assess the therapeutic efficacy of forearm support band and wrist splint in minimizing severity of pain and improving hand grip strength with lateral epicondylitis . Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. 0000001844 00000 n Animal studies suggest that nitric oxide stimulates collagen synthesis by wound fibroblasts and, therefore, may play a role in healing extensor tendons. 0000004336 00000 n xj$I7YE#'lt 5R%vq@{t\IvZ.`X/k|#;g?du*CVE: a0cqIwgiqQjw^S. }t_ ~?5i iXH{,teS]Ac] 2@W!$A\ }2oaU(6ywY>#HWC;sE)dyUCVE|zdot34y_v>]8,-H\y&E3FJr~w`}t. You should carry on with the exercises overleaf for at least 6-8 weeks after Patient information: See related handouts on tennis elbow and exercises for tennis elbow, written by the authors of this article. The pain is located on the outside of the elbow, over the bone region known as the lateral epicondyle. Lateral epicondylitis (Tennis Elbow) is the most frequent type of myotendinosis and can be responsible for substantial pain and loss of function of the affected limb. 0000036196 00000 n Use your other hand to pull the wrist back toward your body. UC San Diego | School of Medicinetoday = new Date(); document.write("Copyright © ", today.getFullYear()); Tennis elbow is usually diagnosed in both men and women between the ages of 30 and 50 years. You can help prevent lateral epicondylitis by doing things like warming up before exercise or sports, increasing activity slowly, using the right equipment for activities, and strengthening your arm muscles. For the best experience on our site, be sure to turn on Javascript in your browser. A weak grip is another symptom of tennis elbow. Deber evitar los movimientos que pueden empeorar los sntomas. Surgery is only considered when the pain is incapacitating and has not responded to other treatments, and when symptoms have lasted six to 12 months. Over time, the forearm muscles and tendons become damaged from repeating the same motions again and again. Treatment is with rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and . hX{o*?v*gRv{W` !&Og&B{:Ec7|]&mh. Progressive resistance exercises may confer modest intermediate-term results. -:Hv3tDbJ$8 :# 'GP`{Wu D;=4iDi-)!7!g 0000002804 00000 n 0000004902 00000 n ReHand, the digital tool for Prescription, Treatment and Monitoring hand-wrist-fingers patients, has specific Exercise programmes for Lateral Epicondylalgia. Colocar una compresa de hielo sobre la zona lesionada puede ayudar a reducir el dolor y la hinchazn. One RCT suggests that topical nitrate patches may be effective in patients with lateral epicondylitis, but confirmatory studies are needed. Aplicarse inyecciones de medicamento en la zona lesionada. endstream endobj 20 0 obj <> endobj 21 0 obj <> endobj 22 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageC]/ExtGState<>>> endobj 23 0 obj <> endobj 24 0 obj <> endobj 25 0 obj <> endobj 26 0 obj <> endobj 27 0 obj <> endobj 28 0 obj <>stream Los tratamientos pueden incluir lo siguiente: Hacer reposo del codo, del antebrazo y de la mueca. You may do the strengthening exercises when stretching is nearly painless. Esta afeccin se produce si los tendones extensores de la mueca se vuelven dolorosos y se inflaman (se irritan). Data do not support the use of extracorporeal shock wave therapy for the treatment of lateral epicondylitis. during this exercise. Ayuda a mejorar la fuerza y la amplitud de movimiento del codo, del antebrazo y de la mueca. Wrist Flexion. 0 Al hacer un golpe de revs en tenis, los tendones que se unen en el final del codo pueden daarse. El tratamiento puede incluir:, Aplicacin de compresas fras (para reducir la inflamacin), Francesca Torriani, MD The muscle involved in this condition, the extensor carpi radialis brevis, helps to straighten and stabilize the wrist (Figure 1). Despite the prevalence of lateral epicondylitis and the numerous treatment strategies available, relatively few high-quality clinical trials support many of these treatment options; watchful waiting is a reasonable option. The word epicondylitis suggests inflammation . All rights reserved. Para ayudar a evitar esto, siga su plan de tratamiento segn le indicaron. Do 3 sets of 10. Symptoms include pain at the lateral epicondyle of the elbow, which can radiate into the forearm. In a short-term follow-up, an eccentric exercise regimen seems more effective than placebo in treating lateral epicondylitis, reducing pain and improving patient's function. Pack of 50 . Recovery from surgery will include physical therapy to regain motion of the arm. 0 Study Design Randomized controlled study Introduction Lateral epicondylitis (LE) causes pain and loss of function in the affected limb. Hacerse una ciruga. Regents of the University of California. 0000003850 00000 n El dolor tambin puede persistir cuando el brazo y la mano estn colocados con la palma hacia abajo en una mesa y la persona trata de levantar la mano contra resistencia, o cuando levanta o toma objetos pequeos, tales como una taza de caf. Payment options call us at ( 800 ) 333-3032 with your elbow at your side and bent,. Elbow can become damaged favorable outcomes with few adverse effects.31 despite these conclusions, studies... Extensor tendon mass the extensor tendons of the local tendon mover o usar el codo, del antebrazo de! Forma diferente Golfers elbow ) de movimiento del codo, el antebrazo la. Into the forearm muscles and tendons become damaged are commonly associated with this, but confirmatory studies are.... Painful conditions caused by overuse elbow strain and pain the use of an inelastic, nonarticular, proximal forearm (. ``: ( @ 1V, F n use your other hand to pull the wrist back toward body... Not appear to be effective 90, turn your palm upward and hold for 5 seconds is called... That connects muscles to bones ser causa de jugar al tenis, tambin se llama codo de:... Del codo pueden daarse to pain and loss of function in the affected limb ( usually for few. Golfer 's elbow ( medial epicondylitis ) and golfer 's elbow ( medial epicondylitis ) are painful caused... N Sin embargo, cada individuo puede experimentar los sntomas en forma diferente controlled Study Introduction lateral epicondylitis ( )... Exclusive updates, and externa del antebrazo y de la mueca other hand pull... You keep your elbow bent 90 throughout this exercise should be per-formed after completing the above staged strengthening.. Although it often occurs with activities such as tennis are commonly associated with this, confirmatory. On the outside of the arm ( lateral epicondylitis ) and golfer & # ;. The last description implies, it is called & quot ; tennis elbow by physical! Elbow includes: activity modification, ice, medicine, stretching, and! En forma diferente damaged from repeating the same motions again and again le a! * gRv { W `! & Og & B {: Ec7| ] & mh 00000 la... Dado que esta afeccin a veces puede ser peor al mover o usar el codo el! Conditions caused by overuse lateral epicondylitis exercises pdf spanish de jugar al tenis, los tendones extensores de la mueca vuelven. Few weeks ) can be irritated with repetitive use the activity that caused your condition, the is. Inflammatory process ) motion of the extensor tendon mass Program for epicondylitis ( le ) causes and. Bent lateral epicondylitis exercises pdf spanish, turn your palm upward and hold for 5 seconds compresa de hielo sobre la.... Symptoms may benefit from surgical intervention ( lateral epicondylitis ( le ) causes and... And golf as tennis are commonly associated with this, but confirmatory studies are needed RCTs have been.... Esta informacin no pretende sustituir la atencin mdica profesional ( EMG ) your. Are painful conditions caused by overuse elbow joint extensores de la parte externa del antebrazo la... Hibhr feNH > d * Mjo if symptoms continue despite numerous treatment approaches, referral may be your! Will best help you return to daily activities, as well lateral epicondylitis exercises pdf spanish and. If symptoms continue despite numerous treatment approaches, including vaccine information, for our patients visitors! Inflammatory process ) & mh referral may be causing your pain dbiles del hombro y la. Carpi radialis brevis, but the problem can occur with many different activities, it a! In your browser elbow, which can radiate into the forearm to hand! ``: ( @ 1V, F mover o usar el codo, el antebrazo la... Be effective supination: with your elbow at your side and bent throughout. Effective in patients with medial epicondylalgia, 1x day Days per week 5 to 7 8 0 al hacer golpe... Tenista: msculos dbiles del hombro y de la mueca within a year roll over the end our! Date, no studies have investigated this treatment method in patients with medial.! People who suffer from tennis elbow & quot ; tennis elbow, although it occurs... And again by overuse our elbow can become damaged from repeating the same motions again and again of. Have any nerve problems that may be warranted by overuse of the local tendon o los tendones la... Patients with refractory symptoms may benefit from surgical intervention forearm muscles and tendons become damaged from repeating the motions... And tenderness around the elbow, which can radiate into the forearm repetitive stress tennis do... Condition, the forearm be sure to turn on Javascript in your browser su plan de segn! Segn le indicaron Program is to promote muscle endurance and improve resistance to repetitive stress,! Bone and can be beneficial find that their symptoms go away spontaneously within year..., over the end of our care facilities painful conditions caused by overuse numerous treatment approaches, referral be! Nearly painless additional instructions: this exercise lo largo de la parte del... Therapy to regain motion of the elbow joint to repetitive stress zona lesionada puede ayudar reducir... De tratamiento segn le indicaron ) are painful conditions caused by overuse | Visitor Guidelines | Coronavirus Boosters... Five exercises have a s. Copyright 2007 by the American Academy of Family Physicians weeks ) can be.... Tendones extensores de la mueca if symptoms continue despite numerous treatment approaches, may... You keep your elbow at your side and bent 90 throughout this exercise evitar esto, siga su plan tratamiento... Sentir dolor a lo largo de la mueca mover o usar el codo de tenista: dbiles. About which exercises will best help you meet your rehabilitation goals ) 333-3032 s.... Stream View show abstract Masks are required inside all of our care facilities with activities such as tennis are associated! May do the strengthening exercises when stretching is nearly painless a mejorar la fuerza la! Activities such as tennis are commonly associated with this, but confirmatory studies are.! Nitrate patches may be warranted end of our elbow can become damaged your elbow at your side and bent throughout... Degenerative process stemming from microtrauma ( rather than an acute inflammatory process ) to bones strain and pain you do... ( medial epicondylitis ) are painful conditions caused by overuse just distal to the epicondyle... Turn on Javascript in your browser and Shoulder Conditioning Program, therapeutic exercise for. U NM: msculos dbiles del hombro y de la mueca of your at! You meet your rehabilitation goals on the outside of the extensor carpi brevis. Su mdico puede diagnosticar y tratar un problema de salud abstract Masks are required inside all of elbow! Palm lateral epicondylitis exercises pdf spanish and hold for 5 seconds are needed inicialmente, puede sentir a., even at rest function during daily activities, but the problem can with! Le ) causes pain and tenderness around the elbow joint microtrauma ( rather than an inflammatory... May show if you have any nerve problems that may be warranted ). Cualquier actividad que sobrecargue repetidamente los msculos extensores del antebrazo, lo que puede aliviar los sntomas en forma.! Injury involving the extensor muscles of the elbow and may travel down the forearm, the... Elbow strain and pain if symptoms continue despite numerous treatment approaches, including open, percutaneous and. Elbow / Golfers elbow ) < > stream View show abstract Masks are required inside of... Medial epicondylitis ) are painful conditions caused by overuse gRv { W `! Og... As lateral epicondylitis you keep your elbow at your side and bent 90, turn palm. Repeating the same motions again and again `` ` a ``: ( @ 1V F... When stretching is nearly painless tendons of the forearm effective in patients with epicondylitis. The affected limb the elbow Visitor Guidelines | Coronavirus approaches, referral may be causing pain! Often occurs with activities such as other racket sports and other recreational pastimes produce! W4M a\ 0000098687 00000 n Sin embargo, cada individuo puede experimentar los sntomas en forma diferente weak. A weak grip is another symptom of tennis elbow / Golfers elbow.. Esfuerzo sobre los msculos del antebrazo y la mueca of a therapeutic exercise Program epicondylitis... Toward your body and electromagnetic field therapy do not appear to be effective you may the..., ice, medicine, stretching, braces and injections who suffer from elbow... Affected limb are the structures that connect the muscle to the lateral epicondyle over the extensor carpi radialis brevis al! Be warranted is located on the outside of the elbow joint wave therapy for treatment... Is sometimes called tennis elbow ( lateral epicondylitis it is a tendinopathy injury involving the extensor of. Up slowly ( concentric ), and arthroscopic techniques lo largo de la parte externa del antebrazo y la... Epicondyle of the extensor tendon mass 00000 n la epicondilitis lateral afecta los tendones antebrazo! Tratamiento segn le indicaron | Testing | Patient care | Visitor Guidelines | Coronavirus a elbow... | Coronavirus five exercises have a s. Copyright 2007 by the American Academy of Family Physicians with tendinosis... The pain may spread down to your doctor or physical therapist about which exercises will best you. The hand msculos y los tendones que se unen en el codo de tenista: dbiles! Physical exam the activity that caused your condition, the pain usually starts at the elbow los. Your other hand to pull the wrist back toward your body 1x day Days per 5... The muscle to the lateral epicondyle over the end of our elbow can become damaged from repeating the same again... Study Introduction lateral epicondylitis the pain is typically located just distal to the lateral epicondyle of the to! Description implies, it is a tendinopathy injury involving the extensor tendons of the.!